Wo m e n s I m a g i n g O r i g i n a l R e s e a r c h

Reisenauer et al.
Ultrasound-Guided Breast Interventions

Womens Imaging
Original Research

JOURNAL CLUB:
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Ultrasound-Guided Breast
Interventions: Low Incidence of
Infectious Complications With
JOURNA L CLUB Useof an Uncovered Probe
Chris Reisenauer 1 OBJECTIVE. The purpose of this study was to determine the incidence of infectious
Robert T. Fazzio complications after ultrasound-guided breast interventions performed with an intermediate-
Gina Hesley level disinfection protocol without an ultrasound probe cover.
MATERIALS AND METHODS. Two independent institutional databases were
Reisenauer C, Fazzio RT, Hesley G searched to identify breast infections in patients who underwent ultrasound-guided interven-
tions between January 2005 and July 2013. The departments of radiology and infectious dis-
eases independently maintained these databases. A comprehensive retrospective chart review
based on periprocedural antibiotic use and clinical documentation of infection was also per-
formed to reduce the likelihood of missing potential infectious complications.
RESULTS. A total of 12,708 ultrasound-guided breast procedures were performed in the
time frame of this study. All potential cases of procedure-related infection were included for
subspecialist review in an effort to give the most conservative (highest) estimate of infectious
complications. Among these cases, 14 documented cases of possible procedure-related infec-
tion were identified, for an overall incidence of 0.11%. All infections were localized skin or
soft-tissue infections and adequately treated with a short course of oral antibiotics. No cases
of more serious infections or sepsis were found. None of the reported infections required IV
antibiotic therapy, percutaneous intervention, surgical intervention, or hospitalization.
CONCLUSION. The incidence of infectious complications after an ultrasound-guided
breast intervention without an ultrasound probe cover is extremely low. Physicians can use
this information in the development of their disinfection protocols and to provide accurate in-
formation in counseling patients during preprocedural consultation.

ltrasound-guided interventionhas tion without specific attention to biopsy mo-

U become a primary tool in the di-

Keywords: biopsy, breast, infection, procedure, ultrasound
DOI:10.2214/AJR.16.16440
Received March 6, 2016; accepted after revision
November 12, 2016.
Based on a presentation at the Radiological Society of
North America 2015 annual meeting, Chicago, IL.
1
All authors: Department of Radiology, Mayo Clinic
Minnesota, 200 1st St SW, Rochester, MN 55905.
Address correspondence to G. Helsey
(helsey.gina@mayo.edu)
AJR 2017; 208:17
0361803X/17/20851
American Roentgen Ray Society
agnostic workup of breast lesions
[110]. The technique for per-
forming a successful ultrasound-guided
breast biopsy has been thoroughly described
in the literature [1113]. These interventions
are safe, effective, and accurate owing to the
lack of ionizing radiation and dynamic visu-
alization capabilities. A large body of publi-
cations have documented the techniques and
complications of continually evolving ultra-
sound-guided breast interventions for diag-
nostic purposes [110].
Although infectious complications of
breast procedures have been studied [18, 14],
we are unaware of a single large-scale study of
the incidence of infectious complications af-
ter ultrasound-guided breast procedures spe-
cifically performed with an intermediate-lev-
el disinfection protocol without an ultrasound
probe cover. The reported incidence of infec-
dality, disinfection protocol, or use of a probe
cover ranges from 0% [1, 3, 69] to 0.12% [5].
The largest cohort in a multiinstitutional study
included 3765 patients who underwent both
percutaneous stereotactic and ultrasound-
guided breast biopsies with a reported infec-
tious complication rate of 0.08% [1].
Our institution proposed escalation of ul-
trasound probe disinfection for breast inter-
ventions to a high-level disinfection proto-
col and use of a probe cover in an effort to
standardize institutional practices. This pro-
posed practice change would have increased
cost and procedure quality control time with-
out a definite benefit to patient safety. There-
fore, we conducted a large-scale review using
prospective and retrospective data to deter-
mine the types and incidence of infectious
complications in an effort to provide infor-
mation about the efficacy of intermediate-
level disinfection without a probe cover and

AJR:208, May 2017 1


accurate infectious risk estimation to pa-
tients undergoing ultrasound-guided proce-
dures. The study was descriptive, and we did
not attempt to identify underlying risk fac-
tors for infectious complications.
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Materials and Methods
Patients
We performed 12,708 ultrasound-guided breast
procedure events for 9066 patients over the 8-year
7-month period January 2005 through July 2013.
In this study time frame, 755 patients declined
authorization to use their medical records for re-
search and were excluded from analysis. Proce-
dure events were defined as a single diagnostic
or therapeutic session, which may have includ-
ed more than one procedure site. For example, a
small minority of patients underwent multisite bi-
opsies in a single session because they had syn-
chronous suspicious lesions, and each biopsy site
was reported in a single dictation. Consequently,
multisite interventions in a single session were
dictated in a combined report in our archiving sys-
tem and referred to as a single procedure event.
All patients who underwent an ultrasound-guided
procedure were included in the search parameters.
Patients who underwent surgical intervention af-
ter an ultrasound-guided procedure were excluded
from the study only after their surgical dates.
Procedures and Techniques
The procedures performed included ultra-
sound-guided biopsies and aspirations. Sono-
graphic guidance was achieved with a Philips
Healthcare IU22 unit. Both L17-5 and L12-5
Philips Healthcare transducers were used; the
L12-5 transducer was used for most of the proce-
dures. Prepackaged sterile biopsy kits were used.
The main contents included a sterile applicator
preparation, a number 11 scalpel, needles, nee-
dle counter, all-purpose sponges, and an adhesive
bandage. Sterile towels were placed around the in-
terventional field. Sterile single-packet ultrasound
gel was used. Approximately 10 mL of lidocaine
with or without a bicarbonate buffer was used for
local anesthesia. Epinephrine was not mixed with
the lidocaine. All procedures were performed by
radiologists using techniques standardized across
our institution with little procedural variation. The
radiologists paid careful attention to preventing
contact between the biopsy needle and the trans-
ducer during sampling (Fig. 1).
Biopsies were performed with either a spring-
loaded core needle or vacuum-assisted biopsy de-
vice ranging from 8 to 18 gauge. Most of the ul-
trasound-guided biopsies were performed with a
14-gauge spring-loaded device; a minority were
performed with a vacuum-assisted device for very
2 AJR:208, May 2017
Reisenauer et al.
small or complex cystic lesions. A small number of
biopsies were performed with a Neothermia device
(Intact Medical Corporation), which is an 8-gauge
device that entails use of radiofrequency technol-
ogy to obtain a surgical-quality specimen for his-
tologic analysis and margin assessment. Aspira-
tions were performed with sterile needles ranging
from 16- to 25-gauge. Of the 12,708 procedures,
9415 were core needle or vacuum-assisted biop-
sies; the other 3293 procedures were needle aspira-
tions. Most of the biopsies were performed with-
out an introducer needle. The average number of
passes for a biopsy or fine-needle aspiration was
approximately five. The biopsy site was routine-
ly marked with a titanium, stainless steel, or ce-
ramic clip immediately after the procedure. After
the biopsy, a procedural assistant immediately ap-
plied firm pressure for 510 minutes in effort to
achieve hemostasis and prevent hematoma devel-
opment. Standardized postprocedural care instruc-
tions were provided to the patient. These instruc-
tions included intermittent cold pack application
for 2 hours, nonaspirin pain reliever as needed,
avoidance of submerging the area for 24 hours,
and avoiding strenuous activity or lifting anything
heavier than 10 pounds (4.5 kg) for 24 hours.
The ultrasound transducer preparation and
disinfection process evolved over the time frame
of our study. Before 2011, the transducer was
cleansed with povidone-iodine (Betadine, Purdue
Products) before the procedure and then soaked
with a disposable towel treated with quaternary
ammonium chloride disinfectant (HB Quat, 3M)
and wrapped for approximately 5 minutes after
the procedure. From 2011 to July 2013, the trans-
ducer was cleansed with a sanitizing wipe (iso-
propanol and quaternary ammonium compounds,
Sani-Cloth Plus, Professional Disposables In-
ternational) to remove any debris. The trans-
ducer was then wrapped with a clean sanitizing
Fig. 1Photograph
shows biopsy technique
and relation between
needle and probe.
wipe for 5 minutes before use in a procedure. Af-
ter the procedure, visible soiling was wiped from
the transducer with a dry disposable towel, and
the transducer was cleaned with a sanitizing wipe
and wrapped with a sanitizing wipe to ensure the
transducer stayed wet for the necessary wet con-
tact time of 5 minutes. All procedures were per-
formed without an ultrasound probe cover.
Identification of Positive Cases
With institutional review board approval, we
reviewed medical records from January 2005 to
July 2013 using infectious disease and radiology
department databases and algorithm-directed ret-
rospective chart review. The infection prevention
and control (IPC) committee at our institution con-
ducts prospective surveillance for selected positive
specimen culture results, including those of patients
who have undergone radiology procedures. Culture
specimens are obtained by the primary physician
on the basis of clinical findings, laboratory data, or
concern for infection. In addition to reviewing cul-
ture data, the IPC committee prospectively moni-
tors daily surgical lists and daily hospital admission
data for visits to the hospital or operating room for
the treatment of infection. When a case is identified
with either of these methods, an infection control
practitioner thoroughly reviews the patients elec-
tronic records with a specific interest in any pre-
ceding intervention. An infection control physician
then reviews the case and decides whether the in-
fection can be attributed to the procedure on the ba-
sis of the procedure timing, clinical circumstances,
and additional pertinent data.
Like the IPC committee, the department of ra-
diology prospectively evaluated all patients who
had undergone ultrasound-guided breast proce-
dures to monitor for complications from 2002
to 2011. This task was performed by a radiology
nurse who placed a telephone call to the patient
 Ultrasound-Guided Breast Interventions

TABLE 1: Possible Procedure-Related Cases of Cellulitis

Technique
No. of Independent
Case No. of Procedure Passes per Site or No. of Age
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No. Procedure Sites per Breast Device Samples Obtained Year (y) Signs and Symptoms Clinical Outcomea
1 Biopsy 2, right 9-gauge vacuum- 2 passes 2006 58 Erythema Oral cephalexin
assisted
2 Biopsy 3, right 14-gauge spring-loaded; 7 passes; 2 passes; 2006 67 Erythema, warm to Oral cephalexin
9-gauge vacuum- 5and6 samples touch
assisted
3 Biopsy; fine-needle 3, right 2 14-gauge core needle; 4 passes 2007 59 Erythema with Oral cephalexin
aspiration 1fine-needle aspiration warmth, nodularity,
of right axilla slight tenderness
4 Biopsy 1, left 14-gauge spring-loaded 5 passes 2009 73 Erythema, slight Oral cephalexin
warmth
5 Biopsyb 1, left 9-gauge vacuum- 4 passes 2010 44 Erythema, tenderness Oral levofloxacin
assisted
6 Cyst aspiration 1, right 20-gauge needle 2011 46 Small hematoma Oral ciprofloxacin
witherythema,
warm to touch
7 Biopsy 2, right 9-gauge vacuum- 8 and 2 passes 2012 49 Patchy erythema Oral dicloxacillin
assisted
8 Biopsy 3, right 14-gauge spring-loaded 4, 5, and 5 passes 2012 42 Erythema, warmth Oral cephalexin
automatic
9 Biopsy 1, left 14-gauge 5 passes 2013 48 Erythema Oral cefadroxil
10 Biopsyb 1, left En bloc radiofrequency 2005 58 Erythema, warmth, Oral amoxicillin
tenderness
11 Biopsy 1, right 9-gauge vacuum- 5 samples 2006 78 Erythema Oral cephalexin
assisted
12 Biopsy 1, left 14-gauge automatic 5 passes 2011 56 Erythema, tenderness Oral cephalexin
13 Biopsy 1, left 13-gauge 3 passes 2012 66 Erythema, pain Oral cephalexin
14 Biopsy 1, left 14-gauge spring-loaded 5 passes 2013 67 Erythema, warmth, Oral levofloxacin
automatic tenderness
a All infections resolved with antibiotic treatment.
bCase detected in radiology surveillance database.

within 48 hours after the procedure and asked
about signs and symptoms related to postproce-
dural infection or hematoma. The nurse specifi-
cally asked whether the patient had increasing site
redness, increasing tenderness, worsening bleed-
ing, abnormal site warmth, or increasing swell-
ing. The nurse asked patients whether they felt
feverish or had measured their temperature. Fi-
nally, the nurse obtained a pain score on a tradi-
tional 10-point scale and compared it with an im-
mediately postprocedural pain score. A pain score
greater than 4 was flagged for provider review. If
a patient was in the hospital, the nurse performed
a chart review. This process was discontinued in
2011 for the breast imaging practice because of the
extremely low postprocedural complication rate.
Last, to ensure adequate infection detection,
a thorough retrospective computer and manual
chart review was undertaken. All charts of pa-
tients who had undergone an ultrasound-guid-
ed breast procedure were searched for keywords
within the electronic medical record 2 days before
and 30 days after the procedure, including infec-
tion, mastitis, and cellulitis. Every biopsy pa-
tient chart included in the study time frame was
searched for antibiotic use 2 days before and 30
days after the procedure. A comprehensive list of
all antibiotics used at our institution (240 antibiot-
ics) was used. Our goal was to find any individu-
al who may have had an infection or received an
antibiotic prescription within the aforementioned
periprocedural time frame. A physician conduct-
ed a manual review of the information to identify
possible postprocedural infectious complications.
All potential cases of procedure-related infec-
tion identified with these three approaches were
further evaluated by an infectious disease physi-
cian. Cases in which the complication was too far
removed from the intervention to ensure causality,
physical examination findings were unsupportive
of infection, or infection was less likely related to
the procedure when the clinical history was con-
sidered were removed from the final incidence cal-
culation. Cases of potential infection thought to be
ambiguous or almost certainly resulting from the
ultrasound-guided procedure were included in the
statistical calculation and designated as possibly
related to the procedure.
Results
Infection Rates
Our institution performed 12,708 ultra-
sound-guided procedure events from Janu-
ary 2005 to July 2013. Among these cases,
14 possible procedure-related infections oc-
curred during that period, for an overall in-
cidence of 0.11%. The postprocedural in-
fection rate for procedures performed with
core and vacuum biopsy devices was 0.14%
(13/9415). The postprocedural infection rate
for smaller-gauge aspiration procedures was
0.03% (1/3293). The infections were 14 cas-
es of skin and soft-tissue infection (Table 1).

AJR:208, May 2017 3


No cases of more advanced infection or sep-
sis were identified.
Infection Prevention and Control Strategy
Versus Radiologic Surveillance Versus
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Retrospective Chart Review
No cases were identified through the pro-
spective data compiled by the IPC committee
database. The low detection sensitivity of the
IPC database should be directly related to the
low severity of the focal skin and soft-tissue
infections and lack of clinical need for blood
or tissue cultures, admission, or surgical drain-
age, which are required for IPC detection.
Two cases were identified in the radiolo-
gy surveillance database. The patients in the
other 12 cases had no symptoms or concerns
during the immediate surveillance period,
experienced symptoms after the 24-hour
surveillance period, or presented after 2011,
when the radiologic surveillance program
was terminated. These 12 patients with pos-
sible procedure-related infections presented
to the emergency department or contacted
their primary caregiver and were identified
in the retrospective chart review.
Nineteen potential cases were identified
in retrospective computer and manual chart
review. Five were eliminated after review
by an infectious disease physician and two
breast imaging radiologists. The cases in
which the complication was too far removed
from the intervention to ensure causality,
cultures were not available, physical exami-
nation findings were unsupportive of infec-
tion, or infection was less likely related to
the procedure when the clinical history was
considered were removed from the final sta-
tistical incidence calculation. Ultimately, 14
cases of potential infection thought possibly
related to an ultrasound-guided procedure
were included in the statistical calculation.
Clinical Outcomes
All patients improved with a short-term
course of oral antibiotics (Table 1). No cas-
es of abscess formation or sepsis were noted.
No additional procedures or hospitalizations
were required.
Discussion
At our institution, the infection rate after
an ultrasound-guided procedure performed
with intermediate-level disinfection without
a probe cover is 0.11%. This infection rate is
statistically comparable to those of lower-pow-
ered studies of variable disinfection protocols
for ultrasound-guided breast procedures [18].
4 AJR:208, May 2017
Reisenauer et al.
Given that procedures were performed
without ultrasound probe covers or a high-
level disinfection protocol, this review fo-
cused on detection of infection when an in-
termediate-level disinfection protocol was
used. From an infectious disease standpoint,
intermediate-level disinfection has been
found to kill vegetative bacteria, mycobac-
teria, most viruses, and fungi [15]. Alterna-
tively, high-level disinfection has been found
to kill all microorganisms except for a small
number of bacterial spores [15]. The imple-
mentation of a high-level disinfection proto-
col and use of a probe cover would increase
microbial coverage with the consequence of
additional cost and time in every procedure.
The U.S. Centers for Disease Control and
Prevention recommends high-level disinfec-
tion and probe cover use for any sonograph-
ic procedure that involves nonintact skin
or use of an endocavitary probe, including
breast interventions [15]. Because of a lack
of clinical studies showing infection risk to a
patient undergoing ultrasound-guided inter-
ventions, this recommendation appears to be
based on theoretic risk and nonclinical data.
Many studies have documented the risk of
nosocomial infection through communal
use of ultrasound transmission gel [1623].
Several studies also have shown the utili-
ty of high-level disinfection and the risk of
perforation of probe covers on endocavitary
probes and during open surgical procedures,
which may predispose the patient to noso-
comial infection [2428]. However, data are
insufficient to show a benefit of high-level
disinfection for a minimally invasive pro-
cedure with limited skin violation in which
needle size ranges from 8- to 25-gauge. To
our knowledge, a clinical study specifically
showing a statistically significant differing
infectious complication rate with different
levels of disinfection or use of probe covers
has not been performed.
In an effort to standardize institutional
practices, the IPC committee at our institu-
tion has proposed escalation of ultrasound
probe disinfection for breast interventions
to a high-level disinfection protocol or use
of a probe cover. The high-level disinfection
protocol proposed would add approximately
15 minutes of probe disinfection and qual-
ity control time to every ultrasound-guided
procedure. Our breast imaging division av-
erages 10 procedures daily, and the addi-
tional disinfection and quality control time
would add approximately 150 minutes of in-
efficient nonvalue-added work daily. This
time would likely decrease the time allotted
for procedures with no substantial addition
to patient safety. Before implementation of a
more costly and time-consuming high-level
disinfection process, the breast imaging di-
vision attempted to validate the safety of in-
termediate-level disinfection without a probe
cover. Given the extremely low risk of infec-
tion identified in this study and contributions
from other related studies, which showed in-
fection rates ranging from as low as 0% [3,
69] to 0.12% [5], escalation of disinfection
to higher than intermediate level for the pur-
pose of nosocomial infection control was de-
termined to be unnecessary in our practice.
Our institutions transducer disinfection
protocol was amended in part on the basis of
the results of this study and adapted as effec-
tive policy. Any sterile nonvascular, nonsur-
gical puncturing procedure that requires an
ultrasound probe requires a minimum of in-
termediate-level disinfection without a probe
cover. Vascular access puncturing proce-
dures and procedures performed in the oper-
ating theater require high-level disinfection
and a probe cover. The decision to continue
with intermediate-level disinfection for ul-
trasound-guided breast procedures resulted
in cost containment while safe and effective
procedural disinfection was maintained.
This study also allowed us to evaluate the
infection incidence as our policies regard-
ing intermediate-level disinfection changed
from 2005 to 2013. We noted no statistically
significant change in infection rates between
cleansing with povidone-iodine in 2005 to
the more expensive and time-consuming in-
termediate-level protocol we currently use.
Current practice guidelines for ultra-
sound-guided breast procedures have been
formulated on the basis of theoretic risk,
data extrapolated from nonclinical studies,
or broadening of the conclusions of modal-
ity-related studies, for example, implemen-
tation of recommendations for ultrasound-
guided biopsy based on risk assessment of
endocavitary probe examinations. Our data
validate that the risk of infection is minimal
when intermediate-level disinfection is used
during ultrasound-guided breast biopsy and
that high-quality care is maintained, daily
work flow is improved, and system waste and
cost are minimized.
Our study had several limitations. The
prospective surveillance by the IPC com-
mittee was based on microbiology records or
complications serious enough to precipitate
hospital admission or an operating room vis-

it. Therefore, minor infections, such as cel-
lulitis, might have been appropriately over-
looked by the IPC committee. Along these
same lines, the decision to order cultures and
additional clinical management depended on
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the caregiver. However, we believe our retro-
spective chart review and radiologic surveil-
lance database search to identify infections
were comprehensive and identified low-se-
verity infectious complications.
A potential limitation was the 48-hour
postprocedural time frame that we used to
define procedure-related bacteremia. Our
institutions experience with other interven-
tions suggests that few procedure-related
cases of bacteremia occur after 24 hours.
The independent retrospective review of
electronic medical records did not identify
any cases of bacteremia or of patients who
needed IV antibiotics that were not identified
in the IPC database.
No data were collected on the incidence or
severity of bleeding complications; the sole
purpose of this study was to assess for in-
fectious complications related to procedural
technique. Any patient who had a hematoma
and chart documentation of infection or re-
ceived a prescription for an antibiotic would
have been revealed in our chart search. Of
the 14 patients with a possible procedure-re-
lated infection, one had documentation of a
small hematoma.
It is possible that additional minor infec-
tious complications were unaccounted for
because over the time frame of this study 755
patients did not authorize use of their medi-
cal records for retrospective chart review and
research purposes. No advanced infections
or abscesses were detected in the IPC data-
base. Therefore, no postprocedural compli-
cation required IV antibiotics, blood or tis-
sue cultures, admission, or surgical drainage,
in this population of 755 patients.
Another limitation was the inability to
differentiate cases that included multisite in-
terventions during the same procedure ses-
sion, needle gauge size, use of an introducer,
and number of passes based on our institu-
tions reporting and archiving systems. Spe-
cifically regarding multisite interventions,
a minority of the procedures performed in-
cluded multiple biopsies of the same breast
for synchronous suspicious lesions. Of the
14 cases attributed to procedure-related in-
fections, five cases were multisite biop-
sies. Some of these patients may have had
increased pain and erythema related to the
procedures rather than to an actual infec-
AJR:208, May 2017 5
Ultrasound-Guided Breast Interventions
tion, which would have falsely elevated the
incidence of infectious complications. Fur-
thermore, the inability to differentiate cases
that included multisite interventions lowered
the overall number of independent proce-
dures that were performed in the time frame
of this study and used for the denominator of
the incidence calculation of infectious com-
plications. If each procedure site and not
each patient who underwent an ultrasound-
guided procedure were accounted for, the
overall infection incidence rate would have
been less than 0.11%. The number of infec-
tions detected during the time frame would
not have been affected by this limitation on
the basis of the methods used for detection
in this study.
Only ultrasound-guided procedures were
evaluated in this study. Assuming similar in-
dications, techniques, and durations of in-
terventions, it is conceivable that the results
with stereotactic techniques or MRI guid-
ance would be similar.
In summary, we found that the incidence
of infection after ultrasound-guided inter-
vention is extremely low with the use of in-
termediate-level disinfection without an
ultrasound probe cover. Furthermore, the in-
fectious complications were low-severity in-
fections that did not require hospitalization
and resolved with oral antibiotics alone. Phy-
sicians can use these data to provide accurate
information to patients during the consent
discussion before procedures and to reas-
sure patients. These data may also be helpful
to providers making decisions about appro-
priate disinfection protocols for ultrasound-
guided breast procedures so that they may
factor in the efficacy of intermediate-level
disinfection, cost containment, system waste,
and longer turnover time requirements for
higher-level disinfection protocols.
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(CDC). Outbreak of Pseudomonas aeruginosa
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87:2729

F O R YO U R I N F O R M AT I O N
This article has been selected for AJR Journal Club activity. The accompanying Journal Club
Study Guide can be found on the following page.

6 AJR:208, May 2017

 Ultrasound-Guided Breast Interventions

AJR Journal Club

Study Guide
Ultrasound-Guided Breast Interventions:
Downloaded from www.ajronline.org by Fudan University Library on 02/23/17 from IP address 61.129.42.15. Copyright ARRS. For personal use only; all rights reserved

LowIncidence of Infectious Complications

WithUseof an Uncovered Probe
Alan Mautz1, Margaret Mulligan2 , Joseph J. Budovec2
1The Aroostook Medical Center, Presque Isle, ME.
2 Medical College of Wisconsin, Milwaukee, WI.

amautz@emhs.org, mmulliga@mcw.edu, jbudovec@mcw.edu*

Introduction
1. What was the purpose of the study? Was the rationale for the study adequately discussed?
2. How would you formalize the studys hypothesis?

Methods
3. What study design was used for the study? What limitations are inherent in this type of study design?
4. What were the inclusion criteria for the study? What were the exclusion criteria?
5. What were the limitations of this study? Were these limitations adequately acknowledged and discussed?
6. The article described three mechanisms of follow-up for patients who had undergone biopsy. Describe the mechanisms of follow-up and
how the study attempts to ensure the most conservative estimate of postprocedural infection rate.

Results
7. Was the research question answered? Are the results replicable?
8. What was the rate of infection after ultrasound-guided biopsy?

Hospital Policy
9. How are infection control policies determined and published at your institution? Can you find such policies if necessary? Does your de-
partment have a mechanism in place to proactively identify potential procedural complications?
10. The article included a brief discussion of the need to balance appropriate infection control with a busy biopsy practice and sound medical
practice. Do you think such a study or change in practice as these authors advocate would be possible at your institution? How does your
institution balance cost containment with risk avoidance and management?

Discussion
11. What are the current infection control protocols in your department? What measures do you take during image-guided procedures to re-
duce the risk of infection, both to the operator and to the patient?
12. Do you anticipate making changes to your departmental practice based on this study? Why or why not?
13. How amenable would your partners, departmental administrators, and hospital administration be if you sought to alter biopsy technique
or ultrasound transducer disinfection protocols?
14. The study provides an economic rationale for performing ultrasound-guided biopsies without a probe cover provided the risk of infection
is not increased. What other considerations merit inclusion in a discussion of infection control protocols? Should patient perception be
considered?

Background Reading
1. Cervini P, Hesley GK, Thompson RL, Sampathkumar P, Knudsen JM. Incidence of infectious complications after an ultrasound-guided intervention. AJR 201;
195:846850
2. Tunstall TD. Infection control in the sonography department. J Diagn Med Sonogr 2010; 26:190197

*Please note that the authors of the Study Guide are distinct from those of the companion article.

AJR:208, May 2017 7